Management of Lateral Ankle Sprains

Introduction

There is no such thing as a flat toe.[1] This is not an injury where patients will be ready to go in two days.[1] Instead, lateral ankle sprains require careful evaluation and management. The following are the main things to consider when dealing with spinal cord compression: delay the progression research for a few days; understand the course of the injury; conduct a comprehensive assessment when the patient can participate; patient compliance with treatment is important; and repeat testing is necessary when there is no improvement.

General Guidelines

Lateral Ankle Sprain

Before choosing an intervention, clinicians should understand the basic guidelines for follow-up fractures including the following:

DO:

• Provide hands-on treatment
• Discuss expectations and timelines
• Expect compliance
• Respect pain
• Think again when there is no progress

DO NOT:

• Order unnecessary imaging
• Have the patient maintain weight bearing when not necessary
• Order immobilisation when unnecessary
• Delay functional movements
• Provide insufficient rehabilitation

Grading System

Lacerda et al[2] found considerable heterogeneity in the literature regarding the classification system of lateral ankle sprains.[2] Most systems use three levels to describe the severity of external ankle sprains:[1]

1. Easy: the patient is able to walk with significant swelling and pain. There are no strings involved.
2. Moderate: the patient complains of pain when walking which is easier when walking and shows edema and moderate pain when palpating muscles. One ligament involved.
3. Severe: the patient is unable to walk there is pain with daily activities there is severe swelling and pain to the touch. Two or more threads are involved.

Another system of labeling the hind toes uses 1 to 3 letters:

• Grade 1: little or no bleeding no point tenderness loss of function decreased total ankle motion by ≤ 5 degrees presence of swelling ≥ 0.5 cm.
• Grade 2: bleeding point tenderness present some loss of function reduced overall ankle motion by more than 5 degrees but less than 10 degrees and less than 2 cm of swelling.
• Grade 3: presence of moderate severe hemorrhage with near complete loss of function resulted in ≥ 10 degrees reduction in overall ankle motion and ≥ 2 cm of swelling.

Management/Interventions

Despite the availability of evidence-based research studies, there are differences in the management of posterior cattle fractures worldwide. It is therefore important to develop evidence-based international clinical guidelines accepted by all physicians treating hindlimb fractures.[3] According to Green et al.[4] most lateral ankle sprain protocols developed for different professions (athletic trainers nurses and physicians and physiotherapists) are outdated and of poor quality.[4]

Acute Phase

General Guidelines:

• Delay the full inspection for up to 14 days (4-14 days); a thorough preliminary assessment is not possible because patient participation is often limited by pain.[1]
• The subjective interview should include the patient’s number of seizures (primary vs serial seizure(s)) location and severity of pain and mechanism of injury. The mechanisms of injury help to identify injured body systems and prioritize the clinical diagnosis.[1]
• The assessment should include physical appearance of the patient’s ankle as well as the ability to stand up and accept weight on the injured foot and the degree of swelling.[1]

Fractures usually occur as a result of inversion and internal rotation regardless of sagittal plane position: plantar flexion or dorsiflexion.[1]

Examples of different mechanisms of injury and types of fractures:

• Forefoot adduction hindfoot inversion and tibial external rotation with the ankle in plantar flexion: one or more of the hindfoot muscles may be involved. It usually affects the anterior talofibular ligament and precedes the calcaneofibular ligament and the posterior talofibular ligament.[5]
• External rotation of the foot and/or excessive ankle dorsiflexion: injury of distal tibiofibular syndesmosis (high ankle dislocation).[5]
• Pronation–abduction pronation–external rotation or supination–external rotation of the foot: medial-ankle sprain.[5]
• Extreme eversion injury: impingement of talus and lateral malleolus.[5]
• Excessive plantar flexion and inversion: an injury to the lateral forefoot region known as cuboid syndrome when the cuboid bone moves out of alignment.[5]
• Foot planted on the ground with ankle in dorsiflexion and inversion: closed packed position can produce compressive forces in mortise joints and shear forces. It causes injury to the hamstrings and the base of the fifth metatarsal. The peroneal nerve may also be involved.[1]

Grades of Ankle Sprains

It can be established on the basis of an initial assessment following known guidelines (grades 1 to 3).

Treatment Principles

• PRICE (1-10 days):
  • Protect: don’t lean your weight walking when you’re stuck.
  • Rest (prevent further injury).
  • Ice: begin within 36 hours with periodic application three times daily (10 minutes on/10 minutes off/10 minutes on). However with cryotherapy Vuurberg et al.[3] found no improvement in rest-time pain activity or inflammation.
  • Coercion: current evidence for the effectiveness of coercion is questionable.[3] But clinicians are using bandages on Tubigrip and DVT stockings despite a lack of evidence of their effectiveness in terms of recovery.
  • Improvement: there are no controlled trials of the effect of rest or elevation in managing acute ankle sprains.[5] One protocol suggests elevating the heart by 15-25 cm to increase venous and lymphatic drainage and reduce inflammation.[7]
• Early Mobilisation: gives good results when pain is respected and the patient is able to walk without stiffness and pain. Kerkhoffs et al[8] found that early mobilization has the following advantages: shorter time to return to sport; significantly reduced inflammation; and radiographic reduction evidence of instability.[8]

CAM Walker Moon Boot

• CAM Boot / Moon Boot or below-knee cast for protection until further examination can be completed:[1]
  • There is good evidence for semi-rigid and lace-up braces.
  • Improve psychological confidence.
  • Cost-effective.
  • Do not affect performance.
  • Effective in reducing swelling.
  • There is no evidence that long-term use of external support causes muscle “weakening” of the lower limbs.

Comprehensive Diagnosis and Comprehensive Treatment Section

The conservative period depends on the severity of the injury and is usually longer:[1]

• 10 days in mild sprains
• 2-3 weeks in moderate sprains
• 6 weeks in severe sprains

Assessment

The assessment must include:

• Muscle strength assessment[1]
• Range of motion measurement[1]
• Balanced Error Control System Test (BESS)[1].
• Special tests, including:
  • Foot and Ankle Ability Measurement (FAAM)[9]
  • Foot and Ankle Outcome Score (FAOS)[9]
  • Star Travel Balance Test (SEBT) [10].
• Pain behavior to help identify involved systems[1].

Lace-up Brace

General Guidelines

• Establish expectations and timelines to ensure patient compliance.[1]
• If possible, mix it with other training.[1]
• Use a lace-up brace to protect the ankle to maintain joint motion and limit dynamic joint positions such as maximum inversion.[3] The brace should be worn during sports and daily activities and can be removed at night or off duty. Comparatively, the use of ankle braces has a better positive effect with plain sports tape or rigid kinesiotape.[11]
• Monitor the patient.[1]
• Provide manual therapy to stimulate hip movements[1][12] in order to:
  • Reduce faulty movement.
  • Offer quality vs quantity.
• Use a pain-free approach.[1]

In summary: exercise should not make the patient feel better.[1]

Therapeutic Management

• Functional rehabilitation[13] is a form of treatment in which the function of the joint is preserved.[3] These include:
  • Closed chain activity exercises. Example: body movements on a firm base[14] squats tandem stance lunges hop to stabilisation.[15]

Squats

Tandem gait

• Postural control and proprioception.[16][17] Strategies include scheduling from simple to complex and predictable to unpredictable environmental constraints.[1]
• The Star Excursion Balance Test (SEBT) assesses active postural control in patients with external ankle fractures.[10]

SEBT

• Motor learning strategies[12][18]
• Cardiovascular fitness
• Leg strength training: leg strength influences somatosensory control of posture and balance.[1] Short leg exercises (SFE) should be added early after proprioceptive re-training after ankle injury.[1] Typically SFE training is conducted three times per week with three groups of 12 repeated statements. Each movement is held for 5 seconds and performed:[1]
  • Weeks 1-4 in a sitting position
  • Weeks 5-8 in a standing position
  • Weeks 5-9 in single-leg stance

Short Foot Exercises

• Increase the range of motion by extending and gathering arms.[19] According to Izaola-Azkona et al.[20] distal fibular mobilization with movement may be the most appropriate treatment option for acute lateral ankle sprain to achieve sustained daily living and athletic activities duty.[20]
• Prevent faulty control techniques including drop landing [21] excessive hip strategy and faulty forefoot position.[22]
• Evaluation of return to athletic rehabilitation.[23][24]

Re-Assessment Phase

If there is no improvement within six weeks the assessment should be repeated including:[1]

• Review of the initial assessment.
• Review of the mechanism of injury.
• A review of intrinsic and extrinsic factors influencing recovery.

Based on the results of this new study, the following actions should be considered:[1]

• Further investigation.
• Referral to a specialist (i.e. a doctor with a specialty in sports or orthopedic surgery).